I shall not now digress to give the clinical details of a case of smallpox; the eruption may be slight or it may be very extensive. It occurs in three forms, discrete, confluent and hemorrhagic. The most dangerous form of smallpox is the confluent, in which the face and arms particularly are covered with large pustular areas of a most disfiguring appearance.
The disease called chickenpox, or varicella, has no relationship to smallpox and does not protect from it, nor does smallpox protect from chickenpox.
HISTORY OF SMALLPOX
There seems very little doubt that the home of smallpox was somewhere on the continent of Africa, although it is true that there are traditions pointing to its existence in Hindustan at least 1000 B.C. One Hindu account alludes to an ointment for removing the cicatrices of eruption. Africa has certainly for long been a prolific source of it: every time a fresh batch of slaves was brought over to the United States of America there was a fresh outbreak of smallpox.[2] It seems that the first outbreak in Europe in the Christian era was in the latter half of the sixth century, when it traveled from Arabia, visiting Egypt on the way. The earliest definite statements about it come from Arabia and are contained in an Arabic manuscript now in the University of Leyden, which refers to the years A.D. 570 and 571. There is a good deal of evidence that the Arabs introduced smallpox into Egypt at the sacking of Alexandria in A.D. 640. Pilgrims and merchants distributed it throughout Syria and Palestine and along the north of Africa; then, crossing the Mediterranean, they took it over to Italy. The Moors introduced it into Spain whence, via Portugal, Navarre, Languedoc and Guienne it was carried into western and northern Europe. The earliest physician to describe smallpox is Ahrun, a Christian Egyptian, who wrote in Greek. He lived in Alexandria from A.D. 610 to 641. The first independent treatise on the disease was by the famous Arabian physician, Rhazes, who wrote in Syriac in 920 A.D., but his book has been translated into both Greek and Latin. The first allusion to smallpox in English is in an Anglo-Saxon manuscript of the early part of the tenth century; the passage is interesting—"Against pockes: very much shall one let blood and drink a bowl full of melted butter; if they [pustules] strike out, one should dig each with a thorn and then drop one-year alder drink in, then they will not be seen," this was evidently to prevent the pitting dreaded even at so early a date. Smallpox was first described in Germany in 1493, and appeared in Sweden first in 1578.
[2] Osler thinks the pesta magna of Galen was smallpox; Marcus Aurelius died of it.
The contributions of Sydenham, the English Hippocrates, to the knowledge of smallpox, are classical.
Throughout the Middle Ages, owing to the very crowded and unsanitary state of the cities of Europe, smallpox was one of the various plagues from which the inhabitants were never free for any length of time.[3] Leprosy, influenza, smallpox, cholera, typhus fever and bubonic plague constituted the dreadful group. In most countries, including England, smallpox was practically endemic; an attack of it was accepted as a thing inevitable, in children even more inevitable than whooping-cough, measles, mumps or chickenpox is regarded at the present time. There was a common saying—"Few escape love or smallpox." In the eighteenth century so many faces were pitted from severe smallpox that it is said any woman who had no smallpox marks was straightway accounted beautiful. Very few persons escaped it in either the mild or the severe form in childhood or in later life.
[3] England was by no means exempt, but it was not infection in
the modern sense that Shakespeare meant when he wrote—
"This England,
This fortress, built by Nature for herself
Against infection and the hand of war."
Now it is characteristic of a microorganic disease that a person who has recovered from an attack of it is immune from that disease for a longer or shorter time, in some cases for the remainder of life. This is, luckily, as true of smallpox as of any of the other acute infections. We do not now need to enquire into the theory of how this comes about; it is a well-recognized natural phenomenon. The modern explanation is in terms of antigens and anti-bodies and is fast passing from the stage of pure biochemical hypothesis into that of concrete realization. Persons who have recovered from smallpox rarely take it a second time; the few who do, have it in a mild form. It follows, then, that if smallpox is purposely inoculated into a human being he will for a long time be resistant to the subsequent infection of smallpox. The fact of smallpox protecting from smallpox is by no means without analogy in other diseases. Thus in Switzerland, in Africa, in Senegambia, it has been the custom for a long time, in order to protect the cattle from pleuro-pneumonia, to inoculate them with the fluid from the lung of an animal recently dead of pleuro-pneumonia. Of course since the time of Pasteur we have been quite familiar with the inoculation of attenuated virus to protect from the natural diseases in their fully virulent form, for instance, anthrax, rabies, plague and typhoid fever.
As it was, then, known to mankind from a very early period that a person could be protected from smallpox by being inoculated with it, inoculation grew up as a practice in widely distant parts of the globe. The purpose of intentional inoculation was to go through a mild attack of the disease in order to acquire protection from the much more serious natural form of the disease—to have had it so as not to have it. A very high antiquity is claimed for this smallpox inoculation, some even asserting that the earliest known Hindu physician (Dhanwantari) supposed to have lived about 1500 B.C., was the first to practice it. Bruce in his "Voyages to the Sources of the Nile" (1790) tells us that he found Nubian and Arabian women inoculating their children against smallpox, and that the custom had been observed from time immemorial. Records of it indeed are found all over the world; in Ashantee, amongst the Arabs of North Africa, in Tripoli, Tunis and Algeria, in Senegal, in China, in Persia, in Thibet, in Bengal, in Siam, in Tartary and in Turkey. In Siam the method of inoculation is very curious; material from a dried pustule is blown up into the nostrils; but in most other parts of the world the inoculation is by the ordinary method of superficial incision or what is called scarification. By the latter part of the seventeenth century inoculation for smallpox was an established practise in several European countries into which it had traveled by the coasts of the Bosphorus, via Constantinople. In 1701 a medical man, Timoni, described the process as he saw it in Constantinople. Material was taken from the pustules of a case on the twelfth or thirteenth day of the illness. As early as 1673 the practice was a common one in Denmark, Bartholinus tells us. In France inoculation had been widely practiced; on June 18, 1774, the young king Louis XVI., was inoculated for smallpox, and the fashionable ladies of the day wore in their hair a miniature rising sun and olive tree entwined by a serpent supporting a club, the "pouf a l'inoculation" of Mademoiselle Rose Bertin, the court milliner to Marie Antoinette. In Germany inoculation was in vogue all through the seventeenth century, as also in Holland, Switzerland, Italy and Circassia. In England the well-known Dr. Mead, honored, by the way, with a grave in Westminster Abbey, was a firm believer in inoculation, as was also Dr. Dimsdale, who was sent for by the Empress Catherine II. to introduce it into Russia. Dr. Dimsdale inoculated a number of persons in Petrograd, and finally the Grand Duke and the Empress herself. The lymph he took from the arm of a child ill of natural smallpox. For his services to the Russian court Dr. Dimsdale was made a Baron of the Russian Empire, a councillor of state and physician to the Empress. He was presented with the sum of 1,000 pounds and voted an annuity of 500 pounds a year. At the request of Catherine, Dr. Dimsdale went to Moscow, where thousands were clamoring for inoculation. The mortality from smallpox in Russia seems to have been still higher than in the rest of Europe. The annual average death rate on the Continent at the end of the eighteenth century was 210 per 1,000 deaths from all causes, while in Russia in one year two million persons perished from smallpox alone. In England in 1796, the deaths from smallpox were 18.6 per cent. of deaths from all causes.